Pediatric Myocarditis Fdne

PEDIATRIC MYOCARDITIS
Dr. Florecilla D. Nelmida-Ecube

Senior lecturer
INTRODUCTION
 MYOCARDITIS is a condition caused by acute or chronic inflammation of the cardiac myocytes

resulting in associated myocardial edema , myocardial injury and necrosis
 Male predominance
 Incidence 0.8 to 2.13 cases per 100,000
 A recognized cause of sudden cardiac death in children and athletes
PATHOPHYSIOLOGY
 Most often caused by a viral or infectious etiology with a predominance of Parvovirus -19 and
human herpesvirus 6
 Other less common causes are autoimmune, medication–related, hypersensitivity reactions
and toxins
 As the pathogen enters the host cell resulting in cell death, an inflammatory cascade of acute
inflammatory cells and mediators such as tumour necrosis factor a, interleukin 1B, interleukin 6
and nitric oxide are released
 The innate immune response releases neutrophils and monocytes from the bone marrow, the
latter of which is thought to drive tissue damage
 Several days after the infection, the adaptive immune response via antigen specific T and B
cells clear the virus, but also causes further damage to myocytes resulting in progression of
fibrosis that can lead to the development of cardiomyopathy
 After the inflammation subsides, the heart may recover, however in some instances, persistence
of viral presence and inflammation can lead to adverse ventricular remodeling
CLINICAL PRESENTATION
 Varies widely, ranging from asymptomatic to critically ill presentation in children
 Children with myocarditis were more likely to be more male with 32% under 4 y/o and 41%
ranging from 15-18 y/o highlighting a bimodal age at presentation ( infancy and adolescence )
 Most common symptoms are fever and viral prodrome, present in at least 50 % of patients and
approx. 2/3 of patients, respectively
 Tachypnea, and gastrointestinal symptoms such as nausea with vomiting and abdominal pain are
also common in children
 Other common presentations are exercise intolerance, chest pain, dyspnea, and palpitations
 More significant presenting symptoms are severe heart failure, ventricular arrythmias and
sudden death due to arrythmia
 The wide spectrum of presentation makes the clinical diagnosis challenging, and typically
depends on the specific myocarditis phenotype, the worst being the fulminant myocarditis
CLINICAL PRESENTATION
 Of the 3 main types of myocarditis, Acute myocarditis typically presents with systolic ventricular
dysfunction either with or without ventricular dilation
 Fulminant myocarditis presents with hemodynamic collapse and cardiogenic shock requiring
inotropic or mechanical support
 Chronic myocarditis is characterized by symptomatic inflammation by laboratory evidence and
normal ventricular function
 Most cases of myocarditis result in recovery; however, dilated cardiomyopathy and sudden death
risks in a minority of patients following myocarditis can occur
EVALUATION
 Laboratory tests –troponin level ,CK MB, BNP/ pro BNP
 ECG – wide QRST angle, low voltage and prolonged QTc associated with adverse cardiac events
 Chest x-ray
 Non invasive imaging studies ( ECHO, cardiac MRI or cardiac computed tomography )
 Endomyocardial biopsy – remains the reference standard for diagnosis of myocarditis
 Echocardiography
TREATMENT AND FOLLOW UP
 Treatment depends on the severity on presentation and stage of illness
 Anti arrhythmias for both atria land ventricular arrhythmias as ventricular arrhythmias are
associated with poor outcome
 Temporary pacing to treat dysrhythmias
 Continuous cardiac monitoring as an inpatient is important for patents with myocarditis
especially in patients with ventricular dysfunction
 For decompensated patients, inotropic support is typically initiated with milrinone, a
phosphodiesterase-3 inhibitor which improves ventricular contractility, afterload reduction,
and improve relaxation
 Inotropic agents with vasopressor activity such as epinephrine are reserved for hypotension
and cardiogenic shock
 Calcium chloride and vasopressin can also be used to augment systemic perfusion
 Extracorporeal membrane oxygenation ( ECMO ) has the unique ability to be deployed
emergent as a short term life saving measure
TREATMENT AND FOLLOW UP
 In more stable patients ,management consists of an oral heart failure regimen such as
Diuretic therapy – to decrease venous congestion
Angiotensin converting enzyme inhibitor ( ACE )- afterload reduction
Angiotensin II receptor blockers –afterload reduction
beta blockers
 Aldosterone antagonists are used for ventricular remodeling
 Carvedilol, a beta blocker has been shown to be cardioprotective and supports ventricular
remodeling
 Immunosuppressive therapy with NSAIDs has been shown to be beneficial for patients with
concomitant pericarditis and pericardial effusion
TREATMENT ANDFOLLOW UP
 Factors that are associated with poor outcome are

limited functional status
elevated BNP
elevated troponin
tachyarrhythmias
ventricular dysfunction
CONCLUSION
 MYOCARDITIS is a rare inflammatory condition in children, which requires
timely diagnosis and appropriate management for prognostication and risk
stratification
 SARS-CoV2 is the newest infectious cause of myocarditis with which long term
sequelae are unknown
 Cardiac MRI is an important non invasive tool that allows for assessment of
ventricular function and tissue characterization.

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PEDIATRIC MYOCARDITIS

Dr. Florecilla D. Nelmida-Ecube

 MYOCARDITIS is a condition caused by acute or chronic inflammation of the cardiac myocytes

 Factors that are associated with poor outcome are

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